By Jill Leslie Littrell, Ph.D.

On February 19, 2012, Lesley Stahl’s “Treating depression:  is there a placebo effect?” aired on CBS 60 Minutes.  Stahl is to be commended for doing an excellent job.  During the broadcast, Stahl interviewed Irving Kirsch, Michael Brown, and Michael Thase as well as providing information on new government policies in the UK on treating persons experiencing mild and moderate levels of depression.

However, the program was marred by a significant omission.  In it, Stahl failed to tell the audience that non-drug psychotherapy has proven to be just as effective as antidepressant drugs without the damaging side effects and high relapse rate that is associated with the drug use.

During the program, Dr. Irving Kirsch provided the bottom line finding from his analyses of FDA data documenting that antidepressants are not effective in treating persons scoring in the mild and moderate ranges of depression assessed by the Hamilton Rating Scale.  Kirsch indicated that antidepressants are effective for persons scoring in the severe ranges of depression.  What Kirsch could have said, which he said in his book, is that even for the severe depressed, there is only a 4 point (out of 51) difference between the placebo and the drug treated.  Moreover, comparing those who are mildly depressed with those scoring in the severe range, the same level of improvement occurs for the mildly depressed and those scoring in the severely depressed range.  The reason for the finding of better performance for the drug in the severely depressed group is that the severely depressed don’t exhibit much change in response to placebo.

Ironically, Michael Thase, the exponent for antidepressants, has admitted that, on drugs, only 47% are in remission.  By the way, the program could have discussed spontaneous remission, but did not.  Even the severely depressed do recover.  Before drugs, the average duration of an episode of depression was 6 months.  Over a two year period, 80% of persons on drugs or without drugs will recover.

In the broadcast, the focus of the discussion was on the short term outcomes from the studies evaluating treatment for eight weeks.  The outcomes for drugs appear even worse if one examines long term.  For example in a study by Maj et al (1992), during a five-year follow-up 72 persons with 76.3% remaining on drug, 75% have relapsed.  In a meta-analysis, Williams et al. (2009) reports that for those who fully recover on drug and remain on drug, 45% will relapse during a three year period.  Fava and Offindani (2011) and Andrews et al. (2011) have compared relapse rates among those on drug versus those not on drugs.  Those on drugs have higher rates of relapse.

Lesley Stahl correctly cautioned that people should not discontinue taking their drugs abruptly.  Stahl did not detail the very dramatic drug withdrawal effects.  In his book, Kirsch indicates that 20% of persons experience withdrawal symptoms when drugs are discontinued.  In fact, in 1994, I argued that the very high rates of depression relapse (around 75% of persons randomized to placebo maintenance) within the 6 months after switch to placebo probably reflects drug withdrawal.    The withdrawal symptoms noted in the literature include mania, motor problems in the jaw, nausea, abdominal cramping, headaches, sleep disruption, blurred vision, numbness, twitches and tremors.  What is even more disturbing, although Stahl advises supervision from the doctor during withdrawal, request for assistance in drug discontinuation will find the doctor unprepared.  There is a literature on how to detox from heroin, alcohol, benzodiazepines.  Similar literatures are unavailable for detox from antidepressants.

There was reference to the side effects in the program, but no specification of what the side effects entail.  Side effects are not trivial.  Most people are aware of the diminished libido and sexual dysfunction.  They may not be aware of the association with suicidal ideation, for which there is a black box warning for young people and children.  Long term, people lose the ability to respond emotionally both to positive and negative stimuli.  (This has been verified with brain imagery.) SSRIs are associated with bone loss.  (Cells in bone express the protein on which Prozac operates).  SSRIs are associated with bleeding problems.  (Platelets also express the protein on which Prozac operates.)  SSRIs are associated with weight gain, metabolic syndrome, loss of vagal tone, an increase in inflammatory markers, and an increased risk for diabetes.

Stahl did report that the British health system is training more psychotherapists.  In the studies evaluating drugs, many have included a psychotherapy control group.   Psychotherapy consistently proves as effective as drugs, although drugs sometimes achieve remission more rapidly by several weeks.  Moreover, persons treated with psychotherapy, in various studies, are less likely to relapse than those treated and continued on drug.  As Kirsch argues in his book, psychotherapy is more cost effective as well.

Stahl also reported that the British are encouraging exercise, which has shown to be effective in preventing and treating depression.  While the 15 minute segment was insufficient time to detail other alternatives, there is an emerging literature on dietary interventions (curcumin, omega-3s, Mediterranean diet) which prevent and ameliorate depression.  Dietary interventions and exercise, unlike antidepressants which increases risk for diabetes and heart disease, will prevent heart disease and diabetes.

Hopefully America can learn from the British.  As Americans move into universal health care coverage, we need to learn from those across the pond how to do it better and more cheaply.

Members of the International Society for Ethical Psychology and Psychiatry are available as media commentators on mental health related issues.

Our varied membership includes psychiatrists, psychologists, professional clinical counselors, academic researchers, educators, lawyers, psychiatric survivors, concerned family members, other mental health professionals, and advocates from around the world.  ISEPP is an independent organization which currently takes no monies from external sources and is run completely by volunteer members.

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Annotated Bibliography on Outcomes for Treated and Untreated

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